CMS’ Proposed Method of Selecting SFP Hospices May Be Flawed

While the hospice community has generally embraced the concept of a Special Focus Program (SFP) to address quality concerns, some are troubled by the government’ methodology for identifying providers.

The U.S. Centers for Medicare & Medicaid Services (CMS) plans to launch the program in 2024, according to language included in the agency’s proposed home health rule for 2024. A chief concern is the algorithm that the agency has decided to use to select providers for the program.

The algorithm is based on a number of quality indicators, including the Hospice Care Index (HCI) score, complaints to CMS about a provider, survey results and Consumer Assessment of Healthcare Providers and Systems (CAHPS) scores. Based on those metrics, CMS will select those in the lowest 10% for the SFP.


Algorithm data likely incomplete

Gaps in these data could mean that some providers could slip through the cracks, according to Larry Atkins, chief policy officer for the National Partnership for Healthcare and Hospice Innovation (NPHI).

“The fundamental problem is that a large portion of hospices don’t report CAHPS data, and only a third of them report star ratings from the CAHPS data. About a quarter of them don’t report HCI data,” Atkins told Hospice News. “A lot of hospices are not going to have the quality data. And for those hospices, [CMS] just generally assumes that they’re operating at about the average level, which means they won’t be selected.”

Further, this methodology could skew the program in favor of large hospices who report a larger breadth of data, according to Ethan McChesney, policy director at NPHI.


It could also mean that some providers who are doing a “decent” job may land in the SFP, ending up in that bottom 10% because poorer performers weren’t included in the data, McChesney said.

A number of hospice industry organizations have raised concerns about the algorithm, while voicing support for the SFP itself.

“LeadingAge is broadly supportive of the idea of [an SFP]. Targeting low-performing hospices for increased oversight via a specific program makes sense and is aligned with our overall thoughts on wanting to support high-quality hospice …,” LeadingAge indicated in public comments on the proposed home health rule. “Our members are concerned that the algorithm, as proposed, would not achieve the goal of targeting the poorest-performing programs.”

This was a common theme among advocacy groups’ comments on the proposed rule, including LeadingAge, NPHI, the National Association for Home Care & Hospice (NAHC) and the National Hospice and Palliative Care Organization (NHPCO).

These four organizations in August penned a joint letter to CMS, calling on the agency to delay the program and provide time to work out a different kind of algorithm. NHPI, LeadingAge, NAHC and NHPCO have been collaborating more closely this year to address quality issues and combat fraud in the space.

“We support a Special Focus Program that is effectively tailored to identify and support poor performing hospices, but really there is a danger of immediately implementing a program with a flawed methodology,” Patrick Harrison, senior director of regulatory and compliance for NHPCO, told Hospice News. “That variable may create red herrings and fail to truly identify those who are not providing care at a level they should be.”

Potential repercussions for hospices

CMS indicated in the proposed rule that 5,943 hospices would be eligible to participate in the SFP and that the agency would select providers from the lowest 10% of performers based on quality data, survey results and other factors.

The program was among the requirements established by the Consolidated Appropriations Act of 2021.

Congress included the hospice language in response to July 2019 reports on hospice quality from the Office of the Inspector General (OIG) in the U.S. Department of Health and Human Services (HHS). CMS expects that implementing these proposals would cost an estimated $5.5 million annually.

If designed similarly to those used in other settings, the SFP would have the power to impose enforcement remedies against hospices with poor performance on regulatory or accreditation surveys. Hospices flagged by the SFP would be surveyed every six months rather than the current three-year cycle.

The program would have the authority to impose fines, suspend reimbursement, appoint temporary management to bring the hospice into compliance or revoke a provider’s Medicare certification altogether.

“The consequences of being selected for the SFP are severe, which is why the selection criteria must be designed to identify the subset of hospices that are truly the poorest performers and most in need of remediation to address quality concerns,” NAHC indicated in its comments on the rule. “An interim performance period (or preview period) would help providers understand the algorithm, learn how their performance compares to others nationally, and identify where they need to target improvements to ensure high-quality care.”

CMS initially pitched the idea for 2022 but instead convened a Technical Expert Panel (TEP) to further guide the development process. The TEP completed its work late last year, and now, per the 2024 proposed home health rule, the agency wants to move ahead with it next year.

No adjustments for patient census

Another key concern about the SFP is that, as proposed, condition-level deficiencies and substantiated complaints would not be scaled to account for the number of beneficiaries that a hospice serves.

This conflicts with recommendations from the TEP, which would have scaled those deficiencies and complaints per 100 Medicare beneficiaries.

“There are some significant deviations [from the TEP recommendations]. For example, when we talk about survey data and deficiencies, there was an understanding that when we look at how these data would be calculated, or how deficiencies would count against the hospice, this would be scaled in according to the size of the hospice,” Harrison said. “The concern here is a senior CMS deviated from that particular approach and this rule, meaning that a hospice agency with a patient census of 500 with a condition-level deficiency would essentially get the same score as a hospice with a census of 50.”

In addition to calling for a delay, the four industry organizations also recommended that CMS conduct a national pilot to test the SFP methodology.

During the pilot period, SFP results would not be posted publicly and providers would receive interim reports on their performance under the program’s designated metrics.

“We’re not asking for a delay just to delay,” Logan Hoover, vice president of policy and government relations at NHPCO, told Hospice News. “We’re really asking CMS to take the time needed to craft a good functioning formula, to work with the TPE and produce a fruitful algorithm.”

Backlog of uncompleted surveys

Another major concern is that CMS has an extensive backlog of hospices that are long overdue for a recertification or accreditation survey, according to the agency’s Quality and Certification Oversight Reports (QCOR). Surveys would provide key elements of the data to be used in the proposed algorithm.

Currently, QCOR reports show that 35.1% of the nation’s 7,152 active Medicare-certified hospices are overdue for a recertification survey. The CMS website shows that “hospice provider and survey information will only be accurate and complete through September 29. 2022,” NHPCO indicated in its public comments on the rule.

“If we’re going to be using surveys as a feature of the algorithm as an input, but we’re only looking at the last 36 months, it doesn’t quite work if a third of your population doesn’t have an up-to-date survey,” Hoover said. “That’s absolutely something that CMS can improve upon.”

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